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ELECTRICIANS’ LICENSE APPLICATION …

VERMONT DEPARTMENT OF PUBLIC SAFETY. Division of Fire Safety Office of the State Fire Marshal, State Fire Academy and State HAZMAT Team ELECTRICIANS' LICENSE APPLICATION INSTRUCTIONS. * applications must be completed in blue or black ink and only original copies will be accepted. Anything incomplete, illegible or containing whiteout will be returned and will delay the APPLICATION process.*. Section 1: APPLICATION Type and Fees Master $ 3 year LICENSE fee. o If Reciprocal, check off from which state and be sure to include a certified letter from reciprocating state (New Hampshire or Maine ONLY), Photocopy of LICENSE is NOT acceptable form of proof. o If applying after holding a Vermont Electrical Journeyman LICENSE for 2 years, submit completed APPLICATION with a copy of your qualifying Vermont Electrical Journeyman LICENSE . o If neither of the above applies submit proof of 16,000hrs of experience through signed affidavits from your previous employers. Journeyman $ 3 year LICENSE fee.

2016JAN Electrical License Application . VERMONT DEPARTMENT OF PUBLIC SAFETY. Division of Fire Safety . Office of the State Fire Marshal, State Fire Academy and State HAZMAT Team

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Transcription of ELECTRICIANS’ LICENSE APPLICATION …

1 VERMONT DEPARTMENT OF PUBLIC SAFETY. Division of Fire Safety Office of the State Fire Marshal, State Fire Academy and State HAZMAT Team ELECTRICIANS' LICENSE APPLICATION INSTRUCTIONS. * applications must be completed in blue or black ink and only original copies will be accepted. Anything incomplete, illegible or containing whiteout will be returned and will delay the APPLICATION process.*. Section 1: APPLICATION Type and Fees Master $ 3 year LICENSE fee. o If Reciprocal, check off from which state and be sure to include a certified letter from reciprocating state (New Hampshire or Maine ONLY), Photocopy of LICENSE is NOT acceptable form of proof. o If applying after holding a Vermont Electrical Journeyman LICENSE for 2 years, submit completed APPLICATION with a copy of your qualifying Vermont Electrical Journeyman LICENSE . o If neither of the above applies submit proof of 16,000hrs of experience through signed affidavits from your previous employers. Journeyman $ 3 year LICENSE fee.

2 O If Reciprocal, check off from which state and be sure to include a certified letter from reciprocating state (New Hampshire or Maine ONLY), Photocopy of LICENSE is NOT acceptable form of proof. o If you have completed the Vermont Apprenticeship Program (within the past 2 years) please include a copy of your completion certificate affidavits not required for this submission. o If neither of the above applies submit proof of 12,000hrs of experience through signed affidavits from your previous employers. Specialist $ (per field) 3 year LICENSE fee. o Submit proof of completion of recognized training program PLUS one year (2,000hrs) experience through signed affidavits for each specialty applying for. o If no formal training program had been completed submit proof of 2 years (4,000hrs) experience through signed affidavits for each specialty applying for. Section 2: Applicant Information Legal Name As it appears on your Driver's LICENSE or other legal form of identification.

3 NO NICKNAMES/ABBREVIATIONS. Date of Birth: Please use format - MM/DD/YY. Social Security Number: REQUIRED on all applications . Mailing Address: Please specify address where you can receive year round mail to include licenses, renewal notices, and additional notices from the Division of Fire Safety. *It is the responsibility of the applicant/licensee to notify the Division of fire Safety if there is a change in address.*. Section 3: Employment Information, &. Section 4: References to qualifications, &. Section 5: Education Information, &. Section 6: Experience Information Please complete all information requested in its entirety. Section7: Affidavit of Applicant All applications MUST be signed AND notarized in order to be accepted. Notary seal only required for oaths taken outside of Vermont. You may also bring your unsigned APPLICATION , and photo Identification to the Division of Fire Safety's Central Office to have it notarized. Section 8: Division Contact Information Please call or e-mail with any questions you have.

4 Remember if the APPLICATION is not correct or complete it will be returned for completion and delay the process. All applications are required to be postmarked or dropped off at the Division of Fire Safety's Central Office TWO WEEKS. PRIOR to the board meeting date otherwise it will be put on a future agenda. Section 9: Compliance Questions All four questions must be answered and page must be signed and dated at the bottom. These questions relate to State of Vermont obligations ONLY. Section 10: Employer Affidavit of Experience Applicant must complete name and address information at the top then this page can be reproduced and mailed/e- mailed/faxed to employers for their completion. HOWEVER, once completed by employer the completed signed ORIGINAL. must be mailed back to applicant to be included with remainder of APPLICATION for submission to the Division of Fire Safety. 2016 JAN Electrical LICENSE APPLICATION VERMONT DEPARTMENT OF PUBLIC SAFETY. Division of Fire Safety Office of the State Fire Marshal, State Fire Academy and State HAZMAT Team ELECTRICIANS' LICENSE APPLICATION .

5 ALL CLASSIFICATIONS. We are required by the state of Vermont to have these forms filled out for our records each time you apply for a Commission, LICENSE or Certification. Be aware that if the information that is requested is not filled out completely it could be returned to you and delay the process. SECTION 1: APPLICATION TYPE AND FEES. Initial APPLICATION Reinstatement Request Additional Testing Request Type S (check category below) $ per field Master $ If Reciprocal please choose: automatic gas/oil heating outdoor advertising refrigeration or NH or ME. (include a certified statement air conditioning appliance and motor repairs well pumps . farm equipment commercial fire alarm gas pumps/bulk Journeyman $ from reciprocating state). plants electrical locksmith lightning rod installations - solar panels SECTION 2: APPLICANT INFORMATION. Full Legal Name: Last, First, Middle Social Security Number: Date of Birth: Gender: Mailing Address: Number/Street or Box City: State: ZIP Code: Physical Address: Number/Street Only - NO Boxes City: State: ZIP Code: Home Phone Number: Cellular Phone Number: Pager Number: Electronic Mail Address (E-Mail): Facsimile Number: SECTION 3: EMPLOYMENT INFORMATION.

6 Employer Name and Address: Contact Name and Phone Number: Duties as employee: Employment Dates( mm/yyyy-mm/yyyy): Employer Name and Address: Contact Name and Phone Number: Duties as employee: Employment Dates( mm/yyyy-mm/yyyy): Employer Name and Address: Contact Name and Phone Number: Duties as employee: Employment Dates( mm/yyyy-mm/yyyy): 2016 JAN Electrical LICENSE APPLICATION SECTION 4: REFERENCES TO QUALIFICATIONS. Applicant will give the name and address of not fewer than three persons, unrelated to applicant, having knowledge of the applicant's electrical background Name: Address: Telephone: 1. 2. 3. 4. SECTION 5: EDUCATION INFORMATION. Name and Location: Dates Attended: Diploma: High School YES NO. College YES NO. Other (Specify) YES NO. SECTION 6: EXPERIENCE INFORMATION. If you currently hold a valid LICENSE in another state please attach a photocopy of each LICENSE . If you have ever applied for a VT LICENSE before please indicate when: Time Served as an Apprentice: Yrs.

7 Mos. Time Served as a Journeyman: Yrs. Mos. Time Served as a Master: Yrs. Mos. Time Served as an Other (please specify): Yrs. Mos. SECTION 7: AFFIDAVIT OF APPLICANT. I hereby certify that this APPLICATION contains no willful misrepresentation or falsifications, and that the information given by me is true and complete to the best of my ability. Date: Signature: Printed Name Sworn and Subscribed before me this day of 20. My Commission Expires Notary Public Signature State of County of (All applications MUST be notarized, notary seal only required for oaths taken outside of Vermont). SECTION 8: CONTACT INFORMATION. Questions: Please contact the Licensing Specialist @ (802) 479-7564 or Mail completed APPLICATION and fees to: Division of Fire Safety Attn: Electrical Licensing Board 1311 US RTE 302, Suite 600. Barre, VT 05641-2351. 2016 JAN Electrical LICENSE APPLICATION SECTION 9: Compliance Questions Applicant's Statement Regarding: Child Support, Taxes, Unemployment Compensation, Fines & Penalties Child Support [15 795] - You must check one of the statements below regarding child support: I do not have any children, OR.

8 I do not owe any child support, OR. I do owe child support, but am under a plan with the Office of Child Support to pay all child support due This certification is in regards to any children residing in Vermont, and where the LICENSE /certificate holder is a resident of Vermont, to any children residing in any other state or territory of the United States. For assistance contact the Office of Child Support, 103 South Main Street, Waterbury, VT 05676 [(802) 241-2180]. Taxes [32 3113] - You must check one of the statements below regarding taxes. All tax returns have been filed. I do not owe any taxes, OR. I owe taxes but am under a plan with the Department of Taxes to pay all taxes due, or the tax payments are under appeal To determine status of a payment plan or appeal, or for assistance, contact the supervisor of tax collections [(802). 828-6809]. Unemployment Compensation [21 1378] - You must check one of the statements below regarding unemployment contributions or payments in lieu of unemployment contributions.

9 I am not now, nor have I ever been, an employer; OR. I do not owe any unemployment compensation, OR. I owe unemployment compensation but am under a plan with the Unemployment Division to pay any and all unemployment compensation due To determine status of a payment plan, or for assistance, contact the department of labor [(802) 828-4254]. Fine or Penalty [4 1110] You must check one of the statements below regarding a fine or penalty issued by the judicial bureau or district court. I am not under any obligation to pay a fine or penalty due to any unpaid judgment issued by the judicial bureau or district court, OR. I am under such an obligation and am in good standing with respect to the obligation because 60 days or fewer have elapsed since the date a judgment was issues, or due to a repayment plan approved by the judiciary For assistance contact the Office of Court Administrator, 109 State Street, Montpelier, VT 05609-0701. [(802) 828-3278]. Statement of Applicant I certify, under the pains and penalties of perjury, that all information I have provided in this APPLICATION is true and accurate.

10 I understand that furnishing false information may constitute unprofessional conduct and result in the denial of my APPLICATION for licensure/certification or renewal. (The maximum penalty for perjury is 15 years in prison and/or a $10,000 fine. 13 VSA 2901). Signature of Applicant: Date: 2016 JAN Electrical LICENSE APPLICATION Section 10: EMPLOYER AFFIDAVIT OF EXPERIENCE. This page may be reproduced if additional employment verification is necessary. If applying for a reciprocal LICENSE this page can be replaced with a certified statement of licensure from either New Hampshire or Maine. Full Legal Name: Last, First, Middle Date of Birth: Telephone Number: Mailing Address: Number/Street or Box City State ZIP Code ~Shaded area below MUST be completed by the certifier in its entirety~. Employer Name and Address: Employment Dates( mm/yyyy-mm/yyyy): Contact Name and Phone Number: Total Hours of Experience: IN THE SPACE BELOW, LIST ALL SPECIFIC TRADE DUTIES APPLICANT PERFORMED OR SUPERVISED IN.


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